Tomás Ripollés

Primary epiploic appendagitis: US and CT findings

Abstract. A retrospective review is presented of seven cases of epiploic appendagitis, with surgical confirmation in one case. The main clinico-analytical data and the US and CT findings are described, as well as the histopathologic features in the sole case that underwent surgical resection. We also calculated the frequency of this entity in patients undergoing emergency abdominal US on clinical suspicion of diverticulitis. In all seven cases the clinico-analytical evidence was nonspecific (localized acute abdominal pain and slight leukocytosis), mimicking in six cases the clinical presentation of sigmoid diverticulitis and in one case that of acute appendicitis. US imaging findings were characteristic: a hyperechoic mass localized under the point of maximum pain, adjacent to the anterior peritoneal wall and fixed during deep breathing. In none of the cases did color Doppler US show flow. CT findings were also typical and showed a mass with a peripheral hyperattenuated rim surrounding an area of fatty attenuation. Overall 7.1 % of patients investigated to exclude sigmoid diverticulitis finally showed findings of primary epiploic appendagitis. Primary epiploic appendagitis thus shows characteristic US and CT findings that allow its diagnosis and follow-up. This entity is much more frequent than previously reported, especially in patients referred for US to exclude sigmoid diverticulitis.

Crohn Disease: Correlation of Findings at Contrast-enhanced US with Severity at Endoscopy

PURPOSE To evaluate the effectiveness of visualization of vascularization at contrast material-enhanced ultrasonography (US) for assessment of the activity of Crohn disease, with severity grade determined at endoscopy as the reference standard. MATERIALS AND METHODS Ethics committee approval and written informed consent were obtained. Sixty-one patients (age range, 21-67 years; median age, 36 years) who had Crohn disease underwent both colonoscopy and US, including color Doppler and contrast-enhanced US, prospectively. To assess the vascularization of the involved bowel loop in a region expected to be seen at colonoscopy, the contrast agent uptake was measured by using quantitative analysis of the enhancement in regions of interest. Measurement of contrast enhancement was assessed as the increase in wall brightness with respect to the baseline brightness. Results were compared with the severity grade determined at endoscopy by using the area under the receiver operating characteristic curve and logistic regression analysis. RESULTS Colonoscopy showed inflammatory lesions in 53 patients (mild disease, seven; moderate disease, 12; and severe disease, 34). Bowel wall thickness and grade at color Doppler US (P = .019 and .002, respectively) correlated with severity grade at endoscopy. Mural contrast enhancement in patients with active disease at endoscopy was markedly increased in comparison with enhancement in patients with inactive disease (P < .001). Multivariate logistic regression analysis revealed that an increase in wall brightness was a significant and independent variable predictive of severity grade at endoscopy. A threshold brightness value of percentage of increase of 46% had a sensitivity and specificity of 96% and 73%, respectively, in the prediction of moderate or severe grade for inflammation at endoscopy. CONCLUSION Quantitative measurements of bowel enhancement obtained by using contrast-enhanced US correlate with severity grade determined at endoscopy. Contrast-enhanced US could be a useful technique to monitor the activity of Crohn disease. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.2531082269/-/DC1.

Effectiveness of contrast-enhanced ultrasound for characterisation of intestinal inflammation in Crohn's disease: a comparison with surgical histopathology analysis.

BACKGROUND Differentiation between predominantly inflammatory versus fibrous-predominant lesions is particularly important in order to decide the optimal therapy in patients with refractory symptoms in Crohns disease (CD). OBJECTIVE The purpose of this investigation was to evaluate the accuracy of several US parameters, especially of contrast-enhanced US, for evaluation of mural inflammation in CD, with histopathology as the reference. MATERIALS AND METHODS Preoperative ultrasound examination, including contrast-enhanced ultrasound (CEUS) was performed in 25 consecutive patients with Crohns disease undergoing elective bowel resection. Ultrasound variables, such as wall thickness, transmural complications, colour Doppler grade, quantitative analysis of the enhancement and the presence and severity of strictures, were prospectively evaluated and compared with the histopathology results. Histopathology grading of acute inflammation using the acute inflammatory score and the degree of fibrostenosis was performed in each segment and the results were compared with all the US variables as well as with a previously defined ultrasound score system for inflammatory and fibrostenotic changes. RESULTS 28 segments were analysed. In pathology analysis there were 12 predominantly inflammatory segments, 9 predominantly fibrostenotic and 7 compound lesions. When the pathology score was dichotomised into two groups (inflammatory and fibrostenotic) the number of stenoses correctly classified by US was 23 out 28, with a substantial agreement (kappa=0.632). There was a good correlation between the sonographic and pathology scores, both inflammation (Spearmans, r=0.53) and fibrostenosis (Spearmans, r=0.50). Transmural complications, colour Doppler grade and percentage of increase in contrast enhancement were significantly associated with the pathology inflammatory score (p=0.018, p=0.036 and p=0.005, respectively). There was a significantly negative association between the colour Doppler grade and the pathologic fibrostenotic score. CONCLUSIONS Ultrasound, including CEUS, can be a useful tool for distinguishing inflammatory from fibrostenotic lesions in CD. This information can be useful in the management of CD.

Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound

AbstractBackground: Gallstone ileus is an uncommon cause of mechanical obstruction. Its high mortality rate can be reduced with earlier diagnosis and treatment. We wanted to determine whether ultrasound (US) performed after plain film increases the sensitivity for the preoperative diagnosis. Methods: We performed a 5-year retrospective analysis of radiologic and sonographic results of 23 patients who had surgery because of gallstone ileus. Results: Riglers triad was identified by plain abdominal film in two patients (9%) and by US in 16 patients (69%). Plain abdominal film contributed to a definitive diagnosis in four cases and to a probable diagnosis in six cases (sensitivities of 17% for definitive diagnoses and 43% for definitive and probable diagnoses). US confirmed the diagnosis in six cases of probable gallstone ileus and provided the diagnosis in seven of 13 patients without suspected gallstone ileus based on plain abdominal film. The best results were obtained by combining plain film and US findings, with sensitivities of 74% for definitive diagnoses and 96% for definitive plus probable diagnoses. Conclusion: The preoperative diagnosis of gallstone ileus significantly increases by combining plain film and US findings.

Contrast-enhanced ultrasonography: Usefulness in the assessment of postoperative recurrence of Crohn's disease

AIM The aim of this study was to assess whether the contrast-enhanced ultrasonography (CEUS) can increase the value of the ultrasonography in the study of postoperative recurrence of Crohns disease (CD). MATERIALS AND METHODS 60 patients with CD who had previously undergone ileocolic resection underwent prospectively both CEUS and colonoscopy within a 3-day period. The sonographic examination included evaluation of bowel wall thickness, transmural complications, colour Doppler grade and contrast-enhanced US. In addition a sonographic score was established. The capacity of CEUS to diagnose endoscopic recurrence, as well as its severity, was assessed by calculating the sensitivity, specificity and positive and negative predictive values, accuracy and odds ratio, with their respective 95% confidence intervals. The areas under the receiver operating characteristic (ROC) curves were also calculated. RESULTS 49 out of 60 patients showed endoscopic postoperative recurrence. Severe endoscopic recurrence was present in 34 patients (57%). Classic ultrasound parameters (wall thickness >3mm and colour Doppler flow) revealed an accuracy of 88.3% for the diagnosis of recurrence. Sonographic score 2, including thickness >5mm or contrast enhancement >46%, improved the results with a sensitivity, specificity and accuracy of 98%, 100% and 98.3%, respectively, in the diagnosis of endoscopic recurrence. The area under the ROC curve was 0.99, in remarkable agreement with endoscopy (k: 0.946). Sonographic score 3, including thickness >5mm, contrast enhancement >70% or fistula identified 32 out of 34 (94.1%) severe endoscopic recurrences. The area under the ROC curve was 0.836, in good agreement with endoscopy (k: 0.688). CONCLUSION CEUS shows excellent sensitivity and specificity for the diagnosis of postoperative recurrence in CD and can also detect severe recurrences.

Usefulness of abdominal ultrasonography in the analysis of endoscopic activity in patients with Crohn's disease: Changes following treatment with immunomodulators and/or anti-TNF antibodies

OBJECTIVE The objective of this study was to analyze the accuracy of abdominal ultrasonography (AUS) in the assessment of mucosal healing in patients with Crohns disease (CD) receiving immunomodulators and/or biological treatment, with ileocolonoscopy as the reference standard. MATERIALS AND METHODS Thirty patients were included in a prospective longitudinal study. All patients underwent ileocolonoscopy and AUS before and after a minimum of one year of treatment. The Crohns Disease Endoscopic Inflammatory Index of Severity (CDEIS) was used for endoscopic assessment whereas AUS was analyzed by means of bowel wall thickness, color Doppler grade and percentage of increase of parietal enhancement after contrast injection. RESULTS In the segmental analysis, endoscopic healing was found in 71.2% of the segments and AUS findings were normalized in 62.8%, with a significant correlation between the two techniques (κ=0.76, p<0.001). In the overall assessment performed after treatment, 18 (60%) patients exhibited endoscopic remission (CDEIS <6 points); of these patients, 15 (83.3%) had normalized sonographic findings, with a good correlation between endoscopic remission and sonographic normalization (κ=0.73, p<0.001). Of the three variables assessed by AUS, parietal thickness was the best variable to predict mucosal healing in both analyses, segmental and global. CONCLUSION Abdominal ultrasonography is a useful and reliable technique for the assessment of the endoscopic response to treatment with immunomodulators and/or biological drugs in Crohns disease. AUS is a highly accurate technique for evaluating the healing of the intestinal mucosa.

Contrast-enhanced ultrasound (CEUS) in Crohn’s disease: technique, image interpretation and clinical applications

BackgroundRecent meta-analysis has demonstrated no significant differences in diagnostic accuracy among different imaging techniques (US, MRI and CT) in the evaluation of Crohn’s disease (CD). High-resolution bowel ultrasound has emerged as an alternative imaging technique for the diagnosis and follow-up of patients with CD, being as accurate as CT and MR for detecting intramural and extramural extension of the disease. B-Mode US can evaluate the localization and length of the affected intestinal segments and allow identification of transmural complications, stenosis and intestinal obstruction. Doppler techniques are tools that visualize and quantify bowel vascularization. Contrast-enhanced ultrasound (CEUS) is a new technique that involves IV administration of an ultrasound contrast agent with real-time examination, providing an accurate depiction of the bowel wall microvascularization and the perienteric tissues. The introduction of imaging quantification techniques enables an objective quantitative measurement of the enhancement.Method and resultsThe article reviews the technique, sonographic findings, advantages and limitations, and clinical applications of contrast-enhanced US in the evaluation of Cohn’s disease. Current CEUS applications in CD are: CD activity assessment, evaluation of inflammatory masses, distinguishing phlegmons from abscesses, characterization of stenosis by differentiating fibrosis from inflammation, monitoring the efficacy of drug treatments and improving the detection of disease recurrence.ConclusionCEUS is an emerging technique that is part of the entire sonographic evaluation, with a role in the diagnosis and follow-up of CD, thus improving therapy planning and monitoring of the efficacy of treatment.

Appendiceal involvement in Crohn's disease: gray-scale sonography and color Doppler flow features.

OBJECTIVE The objective of our study was to evaluate appendiceal involvement in Crohns disease with gray-scale and color Doppler sonography and differentiate it from acute appendicitis. MATERIALS AND METHODS Analysis of the sonographic examinations was performed over 5 years in 190 patients with an established diagnosis of Crohns disease. Data analyzed were as follows: visualization of the appendix; thickness and color Doppler signal (grade 0, 1, or 2) of the appendix and adjacent intestinal loop (cecum, terminal ileum, or both); involvement of other intestinal segments; and abscesses. The findings were compared with those of 49 consecutive patients with sonographic findings of acute appendicitis. RESULTS Thirty-nine patients with Crohns disease (21%) had appendicular involvement. All but one patient showed thickening of the terminal ileum, and 46% of patients also showed thickening of the cecum. The thickness of the ileum was more than 5 mm (only the anterior wall) in 64% of patients. Appendicular hyperemia was seen in 72% of patients. Involvement of other segments was seen in 23 patients (59%) and adjacent abscesses in six (15%). Irregular thickness of the submucosa was seen in nine cases (23%) and fibrofatty proliferation in 19 (49%). In patients with ileocecal regional disease, ileum thickness of more than 5 mm and visible color in the ileum were the most valuable signs, both for the diagnosis of Crohns disease and to differentiate it from acute appendicitis (positive predictive value, 96%; negative predictive value, 74%). CONCLUSION Appendicular involvement in Crohns disease is a relatively frequent event (21%). Sonography and color Doppler sonography may be useful for differentiating Crohns disease with appendicular involvement from acute appendicitis.

Ureteral colic: US versus CT.

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Non-invasive diagnosis and grading of postsurgical endoscopic recurrence in Crohn's disease Usefulness of abdominal ultrasonography and 99m Tc-hexamethylpropylene amineoxime-labelled leucocyte scintigraphy

UNLABELLED Non-invasive techniques aim to be an alternative to endoscopy in the assessment of postsurgical recurrence of Crohns disease (CD). The object of this study was to evaluate the accuracy of abdominal ultrasonography (AUS) and (99m)Tc-hexamethylpropylene amineoxime ((99m)Tc-HMPAO)-labelled leucocyte scintigraphy (LLS) compared with endoscopy in the diagnosis and grading of postsurgical recurrence of CD. Between January 2006 and May 2007, all patients with CD and resection with ileocolic anastomosis were included prospectively. Within three days they underwent an ileocolonoscopy, AUS with evaluation of bowel wall thickness and the presence of Doppler flow, and LLS. Forty patients who met the study conditions were included; 5 patients did not agree to have the ileocolonoscopy and it was not possible to assess the anastomosis in 2 patients. Endoscopic recurrence was detected in 26 patients (78.8%), in 15 of whom it was moderate-severe. For the diagnosis of recurrence, both AUS and LLS showed acceptable sensitivity and positive predictive value, with an accuracy of 72.7% and 78.1%, respectively. The results of the AUS and LLS for diagnosing moderate-severe recurrence were better, with an accuracy of 78.8% and 81.3%, respectively. The best assessment of the severity of the recurrence was obtained with the combination of both techniques (sensitivity, specificity, positive and negative predictive values, accuracy and kappa index were, respectively: 93.3%, 72.2%, 73.7%, 92.9%, 81.8% and 0.64). The variables evaluated, both sonographic and scintigraphic, had areas under the curve that were similar and significantly different from 0.5. CONCLUSION Abdominal ultrasonography and (99m)Tc-HMPAO-labelled leucocyte scintigraphy are two useful non-invasive techniques for the assessment of postsurgical recurrence of Crohns disease.